PHP Medical Director Message - Physician suicide

By: Raymond Truex, Jr., MD, FACS, FAANS

The term Suicide is derived from Latin, with sui referring to “self” and cida meaning “killing.”

Over the past several years, we have experienced a cascade of ominous themes about what’s happening to Americans in general, and to physicians in particular. First, we heard alarms over “burnout,” which this year has evolved into recognition of the rising incidence of suicide. This phenomenon is not limited only to physicians, where the rate of fatality is highest, but in the U.S. population in general.

Review of a simple line graph by year confirms that the 21st century has not been good for self-induced fatalities, and that males are so inclined more than females in the general population. The suicide rate in the general population is 12.3 per 100,000 people. In real numbers, 44,965 suicides occurred in 2016 and 47,173 in 2017.

Suicide seems to be particularly prevalent among Caucasians. The preferred method of choice among men is firearms, as depicted in the 1877 painting by Eduard Manet, while females prefer drug overdose.

Physicians seem to be particularly at risk. Of all occupations, medical practitioners are the most likely to die by suicide. Compare the suicide risk of the general population (12.3 per 100,000) with physicians. The physician suicide rate is almost twice that of the general population (28-40 per 100,000).

Think about that: every year 300-400 physicians take their own lives, or in other words, the equivalent of two to three medical school classes lost each year; or, one physician death every day. Although female physicians attempt suicide far less often than females in the general population, because they have the skill and the means, their actual completion rate exceeds that of both the general population AND that of male physicians. The suicide completion ratio for male physicians is 1.41, while for females it is 2.27, with 1.0 being the reference rate for the general population.

But one must ask, with our post-modern enlightened understanding of the world – why is the incidence of suicide so alarmingly on the ascent? The stigma of suicide has been with us since recorded history. In ancient Athens, a person who took their own life without state approval was denied the honor of a normal burial, and was placed alone in a grave outside the city without a headstone. In 1670 in France, Louis XIV declared that a person who had committed suicide should be drawn through the streets face down, and then hung or thrown on a garbage heap and his property confiscated. During the Enlightenment, a more modern perspective began to dawn, with a shift in public opinion, and by the late 19th century, there was the recognition that suicide was caused by mental illness rather than sin.

Nevertheless, there continues to be a stigma or negative connotation about suicide that persists to the present. This stigma prevents persons at risk from reaching out for help, and that is particularly true for physicians, who fear imposition of sanctions on their medical license by state boards of medicine.

There is no one path to suicide. Suicide is caused by the convergence of multiple risk factors that predispose one to the act of self-harm. Underlying all suicide is mental illness. Mental illness is seemingly handed down family lines in a genetic fashion, and major depression, bipolar disorder, schizophrenia and borderline personality disorder are strongly related to suicidality. Genetics appears to account for 40-50 percent of suicidal behaviors.

There are also acquired causes of suicidal thought and action, which include environmental exposure, such as PTSD in war veterans or victims of abuse, drug and alcohol addiction, response to major illness or loss, a family history of suicide, poverty and isolation. With regard to isolation, physical and social, the accompanying suicide heat map of the United States strikingly demonstrates the effect of isolation in the less densely populated western mountain states.

But these general factors do not explain why the suicide rate is so high among physicians. There must be some factors particular to our profession that predispose us to higher rates of self-harm. Many of these factors have been related to the culture of medicine for many years, and do not explain the recent uptick in physician suicide.

Physicians have always worked long hours, and are encouraged to “power through” in the interest of patient care without complaint or showing weakness. This macho attitude is similar to that found in law enforcement and the military. The culture has long been unforgiving for any sign of weakness, and faint on praise but long on bullying and shaming for any mistake or any deficiency of knowledge or skill.

Because of the limited number of medical school seats, there is a hypercompetitive aspect to medicine beginning in the undergraduate years, leading to an unhealthy “survival of the fittest” mentality. More recently, the competition for limited residency slots has fueled the dilemma, and the need to pay off large student loan debt often requires younger physicians to moonlight in second jobs.

Personality wise, physicians tend toward perfectionism. This sets them up in medical school for self-doubt and depression, which Dr. Danielle Ofri in Slate magazine describes as “The Tyranny of Perfection”:

“So much of medicine is a tyranny of perfection. Medical students are asked to absorb an immense body of knowledge. Prima facie, this is a seemingly reasonable request of our doctors to be. But the number of facts is larger than any human being can realistically acquire, and is ever expanding. Yet we act as though this perfection of knowledge is a realistic possibility. No wonder nearly every student feels like an imposter during his or her training.”

The one socioeconomic factor, however, that best coincides time-wise with the accelerating suicide rate is the corporatization of health care, which has robbed the physician of autonomy and integrity, and the imposition of ever-increasing regulation and oversight by government, insurers and the legal system, bringing with them the threat of lawsuits or unemployment.

Once again, I quote Dr. Ofri, from Slate, who said it best:

“Once in clinical practice, we physicians are faced with a similarly reasonable sounding assignment – take care of your patients. But in reality, this means covering all aspects of your patient’s health, following up on every test result, battling with documentation, navigating insurance company hurdles and administrative mandates. You are exhorted to be cost effective, time efficient, patient centered and culturally competent. You must be conscious of patient satisfaction, and quality indicators. You must avoid liability, but not over order tests. You must document extensively, but not keep patients waiting. You must comply with every new administrative regulation, and keep up your board certifications. And you must of course achieve those all-important ‘productivity measures.’”

To summarize, the path to suicide for any individual is multifactorial, based upon a toxic mixture of genetics, life experience and the unique stresses required of the modern medical practitioner.

At the Pennsylvania PHP, we are very aware that we are dealing with sometimes fragile individuals who are experiencing the type of stressors listed in the right two columns, notably public humiliation and shame, hopelessness, intoxication and severe defeat – all factors in the suicide risk matrix. At the same time, these individuals are often in denial about their possible addiction problems, think that they can solve their own problems and resist our recommendations.

We are aware that we walk a very fine line that could push a depressed participant toward self-harm. In fact, some authors have suggested that PHP’s may play a participatory role in physician suicide by creating inflexible authoritarian dictates. We are cognizant of the suicide risk in our population, and when a participation seems at risk, we perform a suicide risk assessment and will notify a crisis center of an individual in distress.

We certainly have no interest in adding to the many factors causing physician suicide. Our goal is to enable a physician with an impairing problem to confidentially obtain treatment, return to the practice of medicine with reputation and license intact, yet at the same time to protect the citizens of Pennsylvania from harm.